School Employee Disclosure Statement Form printable pdf download

Lehigh Career & Technical Institute

School Employee Disclosure Statement

(Required by 23 PA. C.S.A. S6356 (2) (ii) and 24 PS 1-111)

Name _______________________________________________

Social Security Number _____________________

Address ______________________________________________________

State ______

Zip Code ___________

_________ I am

___________ I am not

a resident of the Commonwealth of Pennsylvania.

I swear/affirm that I have applied for clearance to ChildLine, the Pennsylvania State Police, and the Federal Bureau of

Investigation (where applicable).

I swear/affirm that I have not been named as a perpetrator of a founded report of child abuse or have not been named as

the individual responsible for injury or abuse in a founded report for a school employee.

I swear/affirm that I have never been arrested or convicted of one or more of the following provisions under Title 18 of the

Pennsylvania Consolidated Statues or an offense similar in nature to those crimes listed below under the laws or former

laws of the United States, one of its territories or possessions, another state, the District of Columbia, the Commonwealth

of Puerto Rico, a foreign nation, or under a former law of this Commonwealth:

Chapter 25 (relating to criminal homicide)

Section 2702 (relating to aggravated assault)

Section 2709.1 (relating to stalking)

Section 2901 (relating to kidnapping)

Section 2902 (relating to unlawful restraint)

Section 2910 (relating to luring a child into a motor vehicle or structure)

Section 3121 (relating to rape)

Section 3122.1 (relating to statutory sexual assault)

Section 3123 (relating to involuntary deviate sexual intercourse)

Section 3124.1 (relating to sexual assault)

Section 3124.2 (relating to institutional sexual assault)

Section 3125 (relating to aggravated indecent assault)

Section 3126 (relating to indecent assault)

Section 3127 (relating to indecent exposure)

Section 3129 (relating to sexual intercourse with animal)

Section 4302 (relating to incest)

Section 4303 (relating to concealing death of child)

Section 4303 (relating to endangering welfare of children)

Section 4305 (relating to dealing in infant children)

A felony offense under section 5902(b) (relating to prostitution and related offenses)

Section 5903(c) or (d) (relating to obscene and other sexual materials and performances)

Section 6301(a)(1) (relating to corruption of minors)

Section 6312 (relating to sexual abuse of children)

Section 6318 (relating to unlawful contact with minor)

Section 6319 (relating to solicitation of minors to traffic drugs)

Section 6320 (relating to sexual exploitation of children)

Any offense designated as a felony under the act of April 14, 1972 (P.L. 233, No 64), known as “The Controlled

Substance, Drug, Device and Cosmetic Act.”

I swear/affirm that I have not been convicted of a felony offense of the first, second or third degree other than those

enumerated above for a period of ten years from the date of expiration of the sentence for the offense.

I swear/affirm that I have not been convicted for a misdemeanor of the first degree for a period of five years from the date

of expiration of the sentence for the offense.

School Employee Disclosure Statement Form

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